M3
Order of Clerkships MOST IMPORTANT: Don't stress too much about this. You'll end up doing all the clerkships eventually, and at the end of it the order you did them won't feel too important. There are 2 things worth thinking about, and the rest are just nice if they work out. 1) Many (not all) away rotations will require you to have completed all core rotations in advance. Family medicine is not considered a core rotation by other medical schools. Some schools require you to have completed psychiatry even for a surgery rotation, and some do not - you'd have to check with your school of interest. The safe thing to do is to complete all your core clerkships, at least all but family, during your M3 year. If you must delay another clerkship, psychiatry is probably your safest bet. 2) If possible do your specialty of interest toward the middle - not early, because you don't know anything yet, and not late, because you want to have enough time left afterward to arrange your away rotations, get letters of recommendation, etc. after having experienced the specialty. Minor considerations: The "perfect order" depends on your specialty of interest. *Surgical specialty: Doing OB before would help you know your way around the OR in advance. Doing medicine before gives you a lot of medical management you'll be expected to know. *OB/GYN: Doing surgery before will help you in the OR. Other than that, this clerkship has a unique body of knowledge, ie, the one that you won't have picked up in any other clerkship, except maybe family. *Psychiatry: If you want to do the hospital consult subrotation (good one to do if you're interested in internal medicine), you should do medicine beforehand. Otherwise, doesn't matter. *Family medicine: Peds, OB, medicine in advance would be helpful. *Internal medicine: Doing surgery before would be helpful, but not very important. *Pediatrics: doesn't matter. Psychiatry is the lightest work load, and M2 psych prepared you reasonably well for the shelf. You can use this to get some extra time in your schedule wherever you need it (eg, before your most important clerkship so that you can study ahead, at the end of the year so you can start studying for Step 2, or somewhere in the middle to prevent burnout). Surgery and OB both give you OR experience, so you can try to do whichever one is more important to you later. This way you already know your way around the OR when you come in. Students always say, "do medicine before surgery." *I* felt like doing surgery before medicine helped me in medicine just as much as doing medicine first would have helped me in surgery. Since medicine was more important to me, doing surgery first was the right way to go. If you're considering a surgical specialty, then yes I do recommend doing medicine (and OB) first. At least one other student I have talked to also took surgery before medicine and did quite well and did not feel that he was hindered at all by not having had medicine. This student was also more interested in medicine than surgery. Family medicine requires knowledge from all the other rotations, but not everyone can do it toward the end. All shelf exams have some internal medicine on them, so doing medicine early will probably help you do better on the shelf exams overall. Doing medicine early will also help you get comfortable with patients more quickly because you see more patients on medicine than on other clerkships. General Tips for Doing Well Grading in M3 is a combination of your shelf exam scores and clinical evaluation performed by your preceptors. Preceptors grade you pass / advanced / outstanding on multiple categories, then most clerkkships average these all together and round up. Basically the rules for the shelf are 1) you must pass. 2) Passing is ~60 and below average. 3) above average is Advanced. 4) Around 1 SD above average is Outstanding. They'll remind you of the exact algorithm at each orientation, but again, basically they average your clinical grade and shelf grade together and round up. Doing Well on the Shelf Exams Same formula as for step 1. Read a good review book and do practice questions. "Pretest" is a book series of 500 practice questions for each clerkship. Alternatively, you can purchase a year long subscription to UWorld and do each unit's questions as you do the clerkship - around 200 very high yield questions for each clerkship, but about 1200 internal medicine questions (not a bad idea to try to do about 100 internal medicine questions during each of your other clerkships). UWorld questions are high yield, and less comprehensive; Pretest is more comprehensive but asks several esoteric questions you won't see on the shelf exams. Students do well with both strategies. Most recommended study books *General: If you carry a smartphone or tablet, there are many free apps that can be a great asset during M3 including Medscape (excellent general reference, including drugs), Micromedex (excellent drug reference), AHRQ ePSS (good for double checking screening recommendations), Epocrates (free for med students). These apps are reviewed and rated at http://www.imedicalapps.com/ where they routinely publish a review of the top medical apps for iPhone and Android. While the number of available apps is staggering, the best thing to do is download a handful that look helpful and try them out when you have a little time or you need to look up some information. *Another good general strategy that will help in clinic but less for the shelf exams is to search online for the most recent practice bulletin on a particular topic of interest (from AAP and ACOG especially as these change frequently). These usually aren't too hard to find in pdf format and they are very helpful for knowing the most current recommendatoins for management of various types of patients and diseases. *Pediatrics: Blueprints (concise textbook, "baby Robbins" style), BRS pediatrics (high yield outline, "Goljan" style). You could also consider getting the Harriet Lane handbook for your white coat pocket to use during the clerkship, but use Blueprints or BRS to study for the shelf. USMLE World, Case Files Pediatrics, and PreTest pediatrics are excellent resources as well. *Psychiatry: First Aid for the Psychiatry clerkship is more than adequate. People who take psychiatry before internal medicine will be surprised how much internal medicine is on the shelf. People who took medicine first won't notice this. Do practice questions and pay attention to medical conditions in the psychiatric differential (eg, treat delerium by treating the underlying infection, electrolyte imbalance, thyroid disorder, etc.). *Surgery: NMS Casebook is a fairly comprehensive vignette based book that is helpful for the clerkship (especially the oral exam) and lectures in addition to the shelf. Also, Pestana's kaplan review notes are EXTREMELY helpful - these should be sent to you by your TA, if not google, "pestana surgery notes." Again, if you haven't had medicine yet, you'll be surprised by some of the medicine questions on the shelf: pay attention to medical management of surgical patients, eg, how do you treat hospital acquired (postoperative) pneumonia? What's the workup and management for postop DVT? Be sure to read the Surgical Recall book provided by the clerkship in advance of lectures, especially lectures by Oliphant (he considers your preparation for lecture when he does your grades). Again, USMLE World and Case Files Surgery are excellent preparation for the shelf exam, although Case Files is not comprehensive, so use it in combination with other resources. *Family Medicine: Hardest shelf because anything from nearly any clerkship is fair game. Emphasis on preventative medicine and internal medicine, but OB/GYN and peds are also improtant. Also a short clerkship with less time to study. Consider using a concise Step 2 review book like Boards and Wards (Goljan style), Step Up to Step 2 (Goljan style, more comprehensive than Boards and Wards), Master the Boards (Textbook style but very concise), or Step 2 secrets (brief Q&A format). Step Up to Medicine has also been recommended by students, as this covers most (not all) of the material. Using a good Step 2 book will have the added bonus of getting you familiar with a review book in advance of that test. Another oft-recommended resource for family medicine is the AAFP Board Review Questions. There are over 1000 of them, but they are short and you can choose topics you want to focus on. Go to AAFP.org and you should be able to find them - they are free if you join AAFP (free to join). *Internal Medicine: The clerkship provides Essentials for Students and MKSAP book with practice questions. Book is concise, "baby robbins" style with 2-4 pages on each important disease with references to primary literature if you want to read more. MKSAP practice questions are helpful but easier than shelf questions (the presentations are very obvious). Step Up to Medicine is also commonly recommended. Strongly consider getting Pocket Medicine Handbook of Internal Medicine for your white coat pocket to use on the clerkship. If you are using USMLE World, it is an excellent preparation for the shelf, but there are over 1300 questions so plan to start these questions before IM starts (include a few IM questions during your UWorld sessions on other clerkships) *OB/GYN: Blueprints is excellent for OB/GYN (Concise textbook style). CaseFiles OB/GYN and USMLE World are excellent as well. Clinical Evaluations These are very subjective. Preceptors grade you on your knowledge, your effort, your attitude / enthusiasm and on how much they like you. In general, most preceptors and directors are generous, and about half the students get an outstanding clinical grade. Usually clerkship directors are aware of the harsh graders and will adjust their grades up or give you chances to compensate. Knowledge: Read early in the clerkship (not right before the shelf), read about the cases you see and try to read about the most common / important topics first (ask students about what the common cases are) so that when you get asked about the patient you're presenting you can show off your knowledge. If you get asked something you don't know, think logically about the question and give a thoughtful answer, but do not be afraid to say, "I don't know." (caveat: some, not all, surgeons prefer you to make something up and sound confident than to admit you don't know. It's just the culture of surgery). When (not if) you get asked something you don't know, go read about it that night and come back with a follow-up question that shows you were reading. In my experience, preceptors are actually more impressed by those who are reading and who find out what they don't know than they are by those who seem to know everything. Ask questions that demonstrate you've been reading. "I read that this can also present with ...., do you usually screen for ...?" "I read that you can also treat this with ..., how do you decide which to use?" Effort: In any case there are little things you can do to show you're willing to go the extra mile. Calling the family or nursing home to get more history, calling the past hospital to get old x-rays for comparison, working up secondary or outpatient problems in addition to the patient's chief complaint, reading review papers about your cases and presenting a fact or two from the paper in rounds the next day, etc. etc. etc. Things like this help you get more out of the clerkship and they get noticed by preceptors. Being a little early and leaving a little late can also help. Some preceptors will read your patient notes, making it important to be complete but concise and to show that you've thought about management. Some preceptors will have you do more formal case presentations, making it important to practice delivering a SOAP note. On our campus, most preceptors want an abbreviated presentation focsed on the chief complaint, only the most pertinent positives and negatives from the H&P and the next couple of steps in management. If you have residents, present to them first to help you polish your presentation before rounds. Attitude: If you look bored you're going to be a drag on your attending. They're not going to want to teach you much, which will make you more bored. Attendings teach more / let you do more they know you're interested. Introverts like me are at a disadvantage here, but get over being shy and ask questions, ask to do more in the OR, ask why the attending made the choice they made. When (not if) you're being corrected or chastised, don't sit there with a sour expression on your face and slink away. The only acceptable response is: Smile, "Thank you." Not all attendings have tact, but they really are taking time out of their busy day to try to teach you something. If you are consistently grateful and enthusiastic about learning, they will appreciate you for it. Likability: If you have it, you'll have more fun in 3rd year. If not, go practice. Hospital patients are great for developing people skills because they're bored and they've already opened up to you about personal information. If you're not a "people person," now is your chance to go make some new friends. Most common (and therefore most commonly pimped) topics *Peds: Asthma, RSV, croup, encopresis / bowel obstruction, sickle cell, CF, type 1 diabetes. Make sure you know your age-appropriate well child examinations and vaccination schedules for your outpatient clinic days. *Psych: Depends on your assignments. All: substance abuse, mood disorders, anxiety disorders. Peds psych: ADHD, ODD. Hospital consult: dementia / delierium, capacity evaluations, somatoform disorders, side effects of drugs. *Surgery: Everything about gallbladders, appendicitis, breast lump workup, bowel obstructions, postop complications. This is the one rotation where you know what cases you're going to see in advance - read up ahead of time on whatever procedures you're doing. *Family medicine: very preceptor dependent. Hypertension, dyslipidemia, anxiety and mood disorders, workup for fatigue, screening recommendations / preventative medicine, outpatient management of diabetes, CHF, COPD, atrial fibrillation. *OB/GYN: Preceptor dependent. Prenatal visit schedule (what tests are done when?), first and third trimester bleeding, normal labor and delivery (know this cold), STDs, GYN causes of acute abdomen, cervical cancer screening, postmenopausal bleeding. *Internal medicine: CHF, atrial fibrillation, diabetes, COPD exacerbation, pneumonia, acute pancreatitis.